Bladder Cancer

Overview

Bladder cancer develops when cells in the bladder grow uncontrollably, forming tumors that can spread to deeper tissues or distant organs. The bladder is a hollow muscular organ in the lower abdomen that stores urine produced by the kidneys.

Bladder cancer ranks as the 10th most common cancer worldwide and the 4th most common in men. The disease affects men three to four times more often than women, with most cases diagnosed after age 55 (average age 73). When caught early, bladder cancer has excellent survival rates—over 90% for non-muscle-invasive disease.

About 90% of bladder cancers are urothelial carcinomas (also called transitional cell carcinomas), which begin in the urothelial cells lining the bladder interior. Less common types include squamous cell carcinoma (4%), adenocarcinoma (2%), and small cell carcinoma (rare but aggressive).

Symptoms

Hematuria—blood in the urine—is the most common and often the first sign of bladder cancer. The blood may be visible (turning urine pink, red, or cola-colored) or detectable only under a microscope. Hematuria from bladder cancer is typically painless and may come and go, which can falsely reassure patients that the problem has resolved.

Other early symptoms include frequent urination, sudden urgency to urinate, and painful urination. These symptoms overlap with common conditions like urinary tract infections or cystitis, which can delay diagnosis.

Advanced bladder cancer may cause inability to urinate, back or pelvic pain, bone pain, fatigue, unintended weight loss, and swelling in the legs. These symptoms indicate the cancer may have spread beyond the bladder.

Causes and Risk Factors

Smoking is the single greatest risk factor for bladder cancer. Smokers are three to four times more likely to develop the disease than non-smokers. Carcinogens from tobacco are absorbed into the blood, filtered by the kidneys, and concentrated in urine, where they directly contact the bladder lining for hours at a time.

Occupational chemical exposure accounts for another significant portion of cases. Workers in dye, rubber, leather, textile, and printing industries face elevated risk due to contact with aromatic amines and polycyclic aromatic hydrocarbons. Hairdressers, machinists, and painters also have increased risk.

Chronic bladder irritation from bladder stones, long-term catheter use, or recurrent urinary tract infections can promote cancer development. Radiation therapy to the pelvis for other cancers increases bladder cancer risk years later. Chronic prostatitis and other inflammatory conditions may also contribute. Additional risk factors include arsenic in drinking water, family history of bladder cancer, and the chemotherapy drug cyclophosphamide.

Staging

Understanding bladder cancer staging is essential for treatment decisions. Non-muscle-invasive bladder cancer (NMIBC) comprises about 75% of new diagnoses and includes stage Ta (papillary tumor confined to the inner lining), Tis (flat carcinoma in situ), and T1 (tumor invading the connective tissue beneath the lining but not muscle).

Muscle-invasive bladder cancer (MIBC) penetrates the bladder’s muscle wall. Stage T2 involves muscle invasion, T3 extends through the bladder wall into surrounding fat, and T4 invades adjacent organs such as the prostate, uterus, vagina, or pelvic wall. Lymph node involvement and distant metastases further influence prognosis and treatment.

Diagnosis

Diagnostic evaluation typically begins with urinalysis to check for blood and signs of infection, followed by urine cytology to look for cancer cells. Several urine tumor markers (NMP22, BTA, and others) can support diagnosis but are not definitive alone.

Cystoscopy is the gold standard for diagnosis. During this procedure, a thin camera is inserted through the urethra to directly visualize the bladder interior. Office cystoscopy uses a flexible scope; operating room procedures use a rigid scope and allow biopsy of suspicious areas.

CT urography evaluates the entire urinary tract including the kidneys and ureters, which can harbor related tumors. MRI helps determine tumor depth for staging. Ultrasound can detect tumors but is less sensitive than CT. PET scans and bone scans evaluate potential metastatic spread.

Transurethral resection of bladder tumor (TURBT) is both diagnostic and therapeutic. The surgeon removes all visible tumor tissue through the urethra, providing specimens for pathology that determine tumor type, grade, and depth of invasion.

Treatment

Non-Muscle-Invasive Disease

TURBT is the initial treatment for visible tumors. For low-grade, low-risk tumors, TURBT alone followed by surveillance may suffice. A single dose of intravesical chemotherapy (mitomycin C or gemcitabine) immediately after TURBT reduces recurrence risk.

High-risk NMIBC requires additional therapy. BCG (Bacillus Calmette-Guérin) immunotherapy—a weakened form of tuberculosis bacteria—is the most effective intravesical treatment. Instilled directly into the bladder weekly for six weeks, followed by maintenance treatments, BCG stimulates the immune system to attack cancer cells. It significantly reduces both recurrence and progression to muscle-invasive disease.

Surveillance after treatment is critical. Patients undergo regular cystoscopy and urine testing to detect recurrence early. NMIBC has a high recurrence rate (50-70%), making lifelong monitoring essential.

Muscle-Invasive Disease

Radical cystectomy—complete removal of the bladder—is the standard treatment for muscle-invasive cancer. In men, this includes removing the prostate, seminal vesicles, and nearby lymph nodes. In women, the uterus, ovaries, fallopian tubes, and part of the vagina are also removed.

After cystectomy, urinary diversion reconstructs a path for urine to leave the body. Options include ileal conduit (urine drains into an external bag through a stoma), continent cutaneous diversion (internal pouch emptied via catheter), or neobladder (a new bladder created from intestinal tissue, allowing near-normal voiding).

Cisplatin-based chemotherapy before surgery (neoadjuvant) improves survival and is the recommended approach. Chemotherapy after surgery (adjuvant) is an alternative for patients who did not receive preoperative treatment.

Bladder-sparing trimodal therapy—combining maximal TURBT, chemotherapy, and radiation—offers an alternative for selected patients who wish to keep their bladder or are not surgical candidates. This approach requires careful patient selection and close follow-up.

Metastatic Disease

Metastatic bladder cancer is treated with systemic chemotherapy, most commonly gemcitabine with cisplatin or MVAC regimens. Immune checkpoint inhibitors (pembrolizumab, atezolizumab, nivolumab) have transformed treatment for patients whose cancer progresses after chemotherapy or who cannot tolerate it. Clinical trials offer access to emerging therapies.

When to See a Doctor

Seek medical evaluation immediately for any blood in your urine, even if it occurs only once. Do not assume hematuria is due to a minor cause—bladder cancer is highly treatable when caught early.

Contact your doctor for persistent urinary symptoms including frequent urination, urgency, or burning that does not respond to standard treatment. Unexplained back or pelvic pain, especially with urinary changes, warrants prompt evaluation.

If you smoke, quitting is the single most important step to reduce bladder cancer risk. Occupational exposure to chemicals should prompt discussion with your doctor about screening.